Uninsured trauma patients are more likely to use the ED for follow-up care

Providing access to an outpatient clinic isn't enough to keep some trauma patients who have been discharged from the hospital from returning to the emergency department (ED) for follow-up care, even for such minor needs as pain medication refills and dressing changes, according to new Johns Hopkins research.

Reporting in the Annals of Emergency Medicine, the researchers say that patients with Medicaid, Medicare and those with no insurance were 60 percent more likely to seek such care in the ED. Those living in poor neighborhoods were 70 percent more likely than patients with insurance to head to the ED instead of going to a doctor's office or clinic.

The findings suggest that, for reasons that are not well understood, many patients who could receive less expensive outpatient care won't or can't seek it, the Hopkins team says. These patients, the researchers say, end up receiving far more costly care in the ED, where they have longer waits and add to the notorious crowding that burdens many emergency rooms.

"Just providing patients access to doctors outside of the ER clearly isn't working, especially for those without insurance," says study leader Adil H. Haider, M.D., M.P.H., an assistant professor of surgery at the Johns Hopkins University School of Medicine. "We need better ways to help patients discharged from the hospital receive appropriate follow-up care."

Haider and his colleagues analyzed the records of 6,675 trauma patients admitted to The Johns Hopkins Hospital between 1997 and 2007. Roughly 13 percent of these patients returned to the ED within a month of discharge, yet nearly 90 percent of them were not readmitted into the hospital, suggesting that their ER visit was avoidable and that they could have been treated in an outpatient clinic, Haider says. Among the small number of return patients who were readmitted, the main cause was complications from their original injury and hospitalization.

Along with being uninsured or government insured and living in low-income neighborhoods, black patients and those with more serious injuries were more likely to return to the ED for follow-up care. Patients who were discharged to a rehabilitation, nursing or acute-care facility were significantly less likely to return to the ER than those who were discharged home. The nature of the injury made no difference, the researchers found. Those with penetrating injury, like stabbing or gunshot wounds, were no more and no less likely to seek repeat care in the ER than those with blunt trauma injuries, like those sustained in car crashes.

All trauma patients discharged from Johns Hopkins receive a free follow-up appointment, regardless of insurance. Therefore, access to care shouldn't be an issue even for those who have no insurance and are too poor to afford private care, the investigators say.

"Clearly, there are more factors at play than just having an appointment or access to care," says Haider, who is also co-director of Johns Hopkins' Center for Surgery Trials and Outcomes Research.

To mitigate this problem, the Hopkins staff now makes the initial follow-up appointment for the patient before discharge. Yet, even so, the researchers say, some of the poorest patients may find it hard to believe there is no up-front cost, and they may know they won't have to pay before being seen at the ED. Another possible factor, the researchers add, might be that clinic appointment times are inconvenient for those who cannot take time off work or who have no transportation.

"It may be that going to the ER, typically considered the provider of last resort, is the easiest option," Haider says.

"Regardless of the underlying cause, further research is needed to investigate how the system can be more efficient in taking care of these vulnerable populations," Haider adds. "Improving follow-up care for these vulnerable patients will not only improve the quality of their care, but will also ease the burden on already strained emergency departments and reduce overall healthcare costs."

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